RHINOLOGY

Reconstrucţia de vestibul nazal şi aripă nazală cu cartilaj auricular şi lambou cutanat latero-nazal după excizia unui carcinom bazocelular

 Reconstruction of the nasal vestibule and ala using ear cartilage and folded lateral nasal flap after large basal cell carcinoma excision

Ioana Dumitrescu, Andrada Stan, Silvius Ioan Negoiță

First published: 01 martie 2019

Editorial Group: MEDICHUB MEDIA

DOI: 10.26416/Orl.42.1.2019.2207

Abstract

The continuously growing number of diagnosed skin cancers, of which a great percent is located on the face, has determined plastic surgeons to find better answers and solutions to the challenging questions regarding reconstruction following tumor excision. The only thing complex post-excisional face defects have in common is that they widely vary from a patient to another. The nasal vestibule is the most anterior part of the nasal cavity, enclosed by cartilages and lined by skin anteriorly and respiratory epithelium in its posterior part. The nasal vestibule is a specialized organ with unique characteristics that need to be considered when reconstruction is planned. We present a complex defect of nasal vestibule and ala, following radical excision of basal cell carcinoma.

Keywords
basal cell carcinoma, nasal vestibule, nasal ala, ear cartilage, folded flap

Rezumat

Numărul în continuă creştere al cancerelor cutanate diag­nos­ticate, dintre care un procent important localizat la nivelul feţei, a determinat chirurgii plasticieni să încerce să găsească răspunsuri şi soluţii din ce în ce mai bune la provocările re­con­strucţiei defectelor post-excizionale. Îndrăznim să sus­ţi­nem că singurul lucru pe care defectele de la nivelul feţei îl au în comun este tocmai larga varietate de la un pacient la altul. Vestibulul nazal este partea cea mai anterioară a ca­vi­tăţii nazale, încadrat de cartilajul nazal şi căptuşit cu piele în partea anterioară şi epiteliu respirator în partea poste­rioară. Prezentăm în acest articol un defect complex ce include vestibulul nazal şi aripa nazală, după excizie largă de carcinom bazocelular ulcerat.

A 62-year-old female patient, without any significant medical history, presented to our Plastic and Reconstructive Department for an ulcerated tumor in the nasal vestibule, including the inner lining of the nasal cavity, along with ipsilateral nasal ala retraction (Figure 1), but with no difficulties in breathing. The lesion was moderately painful, with a progressive evolution for the last 18 months.
 

Figure 1. Red arrow – ulcerated lesion. Blue arrow – ipsilateral nasal ala retraction
Figure 1. Red arrow – ulcerated lesion. Blue arrow – ipsilateral nasal ala retraction

After a thorough assessment of the tumor’s size, shape, location and extension, we decided to perform the surgery under general anaesthesia. The aim of the reconstruction was to follow the basic principles of plastic surgery by ensuring reliable structures with adequate blood supply and skin coverage with similar color and texture. After wide tumor excision, the complex defect included full thickness nasal ala along with the underlying lining, the inferior wall of the vestibule and partially the philtrum (Figure 2).
 

Figure 2. Size and shape of the post-excisional defect. Red arrow – inferior vestibular wall. Blue a
Figure 2. Size and shape of the post-excisional defect. Red arrow – inferior vestibular wall. Blue a

Discussion

The reconstructive options for this defect were as follows:

1. Paramedian forehead flap and cartilage graft (a two-stage procedure).

2. Lateronasal cutaneous flap and cartilage graft (a one-stage procedure).
 

Figure 3. Dissection of the lateral nasal skin flap
Figure 3. Dissection of the lateral nasal skin flap
Figure 4. Red arrow – cartilage graft. Blue arrow – folded skin flap. Green arrow – tension-free pri
Figure 4. Red arrow – cartilage graft. Blue arrow – folded skin flap. Green arrow – tension-free pri
Figure 5. Cartilage graft covered with nasal skin flap
Figure 5. Cartilage graft covered with nasal skin flap
Figure 6. Nostril assessment
Figure 6. Nostril assessment

Our final choice was the one-stage procedure, as it also offered superior functional and esthetic outcome to the paramedian forehead flap. A lateral nasal skin flap is carefully elevated and dissected just above the upper border of the defect (Figure 3) in order to preserve the blood supply from the nasal muscle – the external nasal artery and angular artery. Cartilage graft was harvested from the left concha and trimmed similar to the contralateral cartilage regarding angulation and size (Figure 4) and covered by a folded nasal skin flap (Figure 5). We assessed the final nostril dimension and estimated that there will be no airflow obstruction (Figure 6). The rest of the defect was covered with a local transposition flap (Figure 7) sutured in double layers (Figure 8).
 

Figure 7. Transposition flap
Figure 7. Transposition flap
Figure 9. Postoperative aspect
Figure 9. Postoperative aspect
Figure 10. Three-day postoperative aspect
Figure 10. Three-day postoperative aspect

The immediate postoperative aspect was satisfactory for both the surgeons and the patient (Figure 9), with good results three days (Figure 10) and seven days (Figure 11) after the surgery. We removed the skin sutures in the seventh day after surgery and did not register any complications. Unfortunately, the patient lived 380 km from Bucharest and could not comply with the follow-up protocol. Three months after the surgery we had a telephonic conversation with the patient, and we received a picture (Figure 12) from the local dermatologist – the patient had no functional complaints and declared herself satisfied with her final appearance.
 

Figure 11. Seven-day postoperative aspect
Figure 11. Seven-day postoperative aspect
Figure 12. Three-month postoperative aspect
Figure 12. Three-month postoperative aspect

Conclusions

As the most central part of the face, the nose is extremely important in keeping harmonious proportion to one’s face. Full-thickness defects of the nasal ala require cartilage graft in order to prevent alar collapse during inhaling. Cartilage grafts require strong vascular support offered only by flaps. Therefore, when reconstructing post-excisional defects of the nose, the surgeon is challenged with both functional and esthetic targets.  

 

Conflict of interests: The authors declare no conflict of interests.